Introduction to Physical Diagnosis:

Neurology
Developed by Roger L. Weir, M.D.
Associate Professor of Neurology

OUTLINE
1. HISTORY AND PHYSICAL
2. TECHNIQUE
Courtesy
Routine
Actual / Practice

3. ILLNESSES/ DISORDERS / DIAGNOSES

* INTEREST
DIAGNOSIS
TREATMENT
(PREVENTION)
COUNSELLING
N common disorders
uncommon disorders

4. (NEWER DIAGNOSTIC TESTS / TOOLS)

NEUROLOGICAL HISTORY
C/C or Presenting Illness (NP vs Consult)
(see below)
HPI (see below)
PMH
includes tests done
risk factors,
HTN, Diab M.,Dyslipidemia
Head trauma, auto-accident

previous surgery

c/c THE CHIEF COMPLAINT

+or- other neurological problems
HEADACHE. Onset, prior, severity,
frequency, n or v, photophobia, fever
,phonophobia, age, confusion.
LOSS OF CONSCIOUSNESS. seizure,
syncope, other
R WEAKNESS. Duration, onset, vision,
sensation, headache,
LOW BACK PAIN.duration,initial cause, rx

c/c contd
DIZZINESS. Vertigo, tinnitus, double
vision, faintness, ataxia, inducer, reliever,
rising, flat, turning in bed, hearing.
NUMBNESS OF HAND. Which fingers,
neck pain
DIFFICULTY WALKING. Pain, where pain
DIFFICULTY SPEAKING. Understanding,
being understood

c/c contd.
BLURRED/DOUBLE VISION one or two,
in which plane,
SEEING THINGS. ?hearing voices,
threats, delusions, crawling in skin, drug
use, FH.

History Present illness

Onset date; recheck for a remote onset

Speed of onset
Prevalence/persistence/? Intermittent
Severity/ variations in severity
Precipitants
Relievers
Medication effect
Associated symptoms
Associated symptoms in the past

Neurological History

FAMILY HISTORY
Risk factors suggested
Sickle Cell anemia
Muscular Dystrophy
Myocardial Infarction
Spinocerebellar degeneration

Neurological History
SOCIAL HISTORY
Alcoholism, Cocaine use
Nicotine use,
Occupation
Living situation
Spousal/emotional status
ROS

Multiple. See outline of Neuro exam.

THE NEUROLOGICAL
EXAMINATION
MENTATION AND SPEECH
CRANIAL NERVES (2 to 12)
MOTOR FUNCTION
(Normal, Impaired, Abnormal movement)

COORDINATION (Cerebellar Function)

REFLEXES (DTRsdeep tendon reflexes)
SENSATION
MENINGEAL SIGNS
STATION AND GAIT
SPINE / MUSCULO-SKELETAL

MENTATION AND SPEECH

Level of Consciousness:
Awake, stupor, coma

Memory:
Digit span (reverse versus forward), recent, remote, fund of
information

Calculations:
Arithmetic, money (?education)

Draw a clock
Draw a person
Copy a figure
Confusion
Denial / Inattention

MENTATION AND SPEECH

Anosognosia
Apraxia
Distractibility
Hallucinations:
Auditory, visual, other

Mood:
anxiety, depression

Appropriateness of interaction

MENTATION AND SPEECH

Speech Production:
Quantity, flow, loudness, syllables, sounds, words

Following Commands:
Verbal, written, gestures

Naming
Repetition:
sentence, word, counting, singing

Reading
Writing:
spontaneously, copying,

Calculations / arithmetic

CRANIAL NERVES
1. 2*. 3*. 4. 5. 6*, 7*, 8*, 9, 10, 11, 12

CN1: R/L nostril, non-irritant, diminution with

age

*CN2: Visual acuity, visual fields, light reflex,

accommodation, optic disc

*CN3: Light reflex, accommodation, EOM, lid

opening, pupil size

CN4: Depression of the adducted eye

CN5: Facial sensation, jaw closure, side/side

jaw movement

*CN6: Abduction of the eye

CRANIAL NERVES
1. 2*. 3*. 4. 5. 6*, 7*, 8*, 9, 10, 11, 12
*CN7:
Brow elevation, eyelid closure, smile
facial droop +autonomic/sensory
*CN8: Auditory acuity, dizziness, balance,
tinnitus, nystagmus, Weber, Rinne
CN9: Gag reflex, swallowing
CN10: Vocal cord movement + autonomic
CN11: Sternocleido-Mastoid, Trapezius
CN12: Tongue deviation, atrophy, fasciculations

MOTOR EXAMINATION
WASTING / HYPERTROPHY
(Duchenne muscular
dystrophy)
FASCICULATIONS (evidence of lower
motor neuron dysfunction)

MOTOR EXAMINATION
STRENGTH:
Proximal (characteristic of muscle problem),
distal (characteristic of periph. neuropathy),
*Right vs. Left,
upper limbs, lower limbs,
nerve root distribution,
nerve distribution,
severity(0 to 5),
pain effect,
other.

MOTOR EXAMINATION
RIGIDITY, SPASTICITY, OTHER
SPEED OF MOVEMENT
ABNORMAL INVOLUNTARY MOVEMENTS
eg tremor

OTHER ABNORMAL MOVEMENTS

eg epileptiform.

COORDINATION
Cerebellar function
Reason for doing the strength test before
coordination is to know if incoordination is
due only to muscle weakness
May apparently vary with strength

COORDINATION
Cerebellar function
*FINGER / NOSE test:

proximal, transitional, distal, moving target

?past pointing, ?intention tremor

RAPIDLY ALTERNATING MOVEMENTS:

supination/pronation, tapping rhythm

*HEEL/SHIN test:
proximal, transit
ankle dorsiflexion

*TANDEM WALKING: (?mechanical impediment)

A little difficult in fat persons and mechanically impaired

CHECK / REBOUND:**

Cerebellar testperson with disfunction will have more rebound

POSTURE
STANDING BASE: width, stability
GAIT: stable, asymmetric, ?type

REFLEXES

Always compare the right with the left

Deep tendon, pathological, superficial

SUPERFICIAL:

abdominal, cremasteric
Abdominal reflex disappears in the presence of upper motor neuron
(multiple sclerosis)

PATHOLOGICAL:

Babinski, snout, Hoffman,

Ankle clonus, other clonus
Oppenheim, Chaddock

DEEP TENDON(R/L):

upper/lower, proximal/ distal

BJ, TJ, SJ
KJ , AJ
Jaw jerk (corticobulbar test), pectoralis, adductor.

GRADING:
0, 1, 2 , 3, 4
where 2 represents an average reflex.

SENSATION

R/L, Prox/Distal, Upper/Lower, Nerve, Nerve root,

dorsal column, spinothalamic,
large fibre/ small fibre
CNS

Light touch(acuity, subjective types)

Pin: metal, wood (NO reusable sharp points)
Temperature: cold metal vs. uncold wood; other

Position sense( in 4 limbs), distal with or without proximal

Vibratory sense (requires judgement)

Touch:
Double simultaneous stimulation
Graphesthesia
Stereognosis
Two-point discrimination
Point localization

MENINGEAL SIGNS
bacterial/ viral/other meningitis
& subarachnoid hemorrhage

NECK STIFFNESS
KERNIG
BRUDZINSKI
PHOTOPHOBIA
EYEBALL TENDERNESS (least
important)

(STRAIGHT LEG RAISING)

(?Headache, vomiting, lethargy)

SPINE/MUSCULO-SKELETAL
Spine tenderness:
Cervical, Lumbar, Thoracic
Sacro-iliac joints

Straight leg raising (for herniated disc?)

Muscle tenderness or tenseness of:

Scalp muscles
Cervical paraspinals
Lateral neck muscles
Scapular region muscles
Lumbar paraspinals
Lateral sacrum

Patricks Sign (for detecting hip problem)